Buale Sakow Nutrition Assessment - April 2006
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Buale Sakow Nutrition Assessment - April 2006
BUALE AND SAKOW DISTRICTS MIDDLE JUBA REGION SOMALIA Nutrition Assessment Report April 2006 Food Security Analysis Unit (FSAU/FAO) World Vision International United Nations Children’s Fund (UNICEF) World Food Program (WFP) Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP TABLE OF CONTENTS TABLE OF CONTENTS.............................................................................................................. 2 ACKNOWLEDGEMENT ............................................................................................................ 3 ABBREVIATIONS AND ACRONYMS ..................................................................................... 4 EXECUTIVE SUMMARY .......................................................................................................... 5 SUMMARY FINDINGS FOR BUALE SAKOW ASSESSMENT............................................. 6 1 INTRODUCTION ................................................................................................................ 7 2 BACKGROUND INFORMATION ..................................................................................... 8 3 METHODOLOGY ............................................................................................................. 12 4 THE ASSESSMENT RESULTS........................................................................................ 16 5 DISCUSSION AND CONCLUSIONS .............................................................................. 29 6 CONCLUSION AND RECOMMENDATIONS ............................................................... 30 7 APPENDICES .................................................................................................................... 30 8. ASSESSMENT TEAM....................................................................................................... 49 9. REFERENCES ................................................................................................................... 50 2 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP ACKNOWLEDGEMENT WVI provided the logistical support and organization, and with funding from UNICEF, met the cost of enumerators (mainly WVI staff), supervisors, data entry and vehicle hire. WFP provided their National VAM officer who worked together with the FSAU food security analyst collected qualitative data. FSAU provided technical coordination of the assessment through two nutritionists, four nutrition field analysts (supervisors) and a food security analyst. FSAU trained the assessment team, coordinated and supervised data collection, entry and analysis, produced the draft and final reports. Participating agencies (FSAU nutrition and food security team, WVI, UNICEF and WFP) reviewed and provided comments on the draft report which have been incorporated into this report. FSAU, WVI, UNICEF and WFP greatly appreciate the contribution of local authorities in ensuring security for the fieldwork in Buale and Sakow districts. The data could not have been obtained without the co-operation and support of the communities assessed, especially the mothers and caregivers who took time off their busy schedules to respond to the interviewers. Their involvement is highly appreciated. FSAU, WVI, UNICEF and the WFP also express their sincere appreciation to the entire assessment team for the high level of commitment, diligence and ingenuity demonstrated during all stages of the assessment. 3 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP ABBREVIATIONS AND ACRONYMS ARI FAO FSAU GAM HAZ HAZ IDP MCH MUAC NCHS NGOs NGO NIDs SACB SMART UN UNDP UNHCR VAD UNICEF WAZ WFP WHO WHZ Acute Respiratory Infections Food and Agriculture Organisation Food Security Analysis Unit Global Acute Malnutrition Height- for- Age Z scores Height for Age Z scores Internally Displaced Person Maternal and Child Health Mid Upper Arm Circumference National Centre for Health Statistics Non-Governmental Organisations International Non-Governmental Organisation National Immunisation Days Somalia Aid Coordination Body Standardised Monitoring & Assessment of Relief and Transitions United Nations United Nations Development Programme United Nations High Commission of Refugees Vitamin A Deficiency United Nations Children’s Fund Weight for Age Z Scores World Food Programme World Health Organisation Weight for Height Z scores 4 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP EXECUTIVE SUMMARY Buale and Sakow districts are located in Middle Juba Region. Buale district has an estimated population size of 46,520 and Sakow, 87,935 (WHO, 2005 NIDS figures further verified by the survey team). The two districts are located along the Juba River. The FSAU led Post Deyr 2005/6 Food Security and Nutrition situation analysis/projections for January through June 20061, classified most parts of Buale and Sakow districts as faced with a humanitarian emergency and other areas, an acute food and livelihood crisis/high risk of humanitarian emergency. This was primarily attributed to the impact of below normal Gu 2005 rains, followed by completely failed Deyr 2005/6 rains which resulted in complete crop failure. This impacted negatively on the lives and livelihoods of the populations groups. From April 22nd-27th, 2006, FSAU, WVI, UNICEF and WFP conducted a joint assessment to analyze the nutrition situation and retrospective mortality rates in Buale and Sakow districts. A 30 by 30 cluster sampling methodology was used and 898 children and 347 adult women aged 15 – 49 years were assessed. Mortality data was collected from 927 households. Findings indicate global acute malnutrition rate (weight for height <-2 Z score or oedema) of 21.9% (CI:19.3-24.8) and severe acute malnutrition (weight for height <-3 Z score or oedema) of 6.6% (CI:5.18.4). This highlights a critical nutrition situation (WHO) and a worsening one when compared to long term estimates of malnutrition for the area. Additionally, about 40% of the 97 assessed pregnant women had MUAC < 23.0 cm, while 3% of the 250 non-pregnant women had MUAC <18.5cm and were categorized as malnourished. The crude mortality rate was 0.61 (CI: 0.39 – 0.83) deaths/10,000/day and the under five mortality rate 1.98 (CI:1.26 – 2.69) deaths/10,000/day which are acceptable (WHO). About 38% of the children were introduced to complementary foods at the age of 6 months and above. A summary of assessment findings is indicated in the table below. Qualitative data indicates poor household food access due to high food prices, and general unavailability of animal products, most of the livestock having either died, migrated back to areas of origin or, in too poor body condition to provide milk and milk products. The critical nutrition situation is attributed to poor dietary intake and presence of communicable diseases. About 30% of the children came from households consuming a poorly diversified diet comprising of three or fewer food groups2. Previous studies have indicated an association between malnutrition and dietary diversity. Additionally, about 49% of the children reported having suffered from an episode of a communicable disease in the preceding two weeks. The high disease incidence may be partly attributed to limited access to preventive and curative health care services, with Sakow district having no health facility. However, in Buale, WVI/UNICEF operates an MCH/OPD/EPI with 38 health posts. Additionally, about 75% of the children came from households which consume water from unsafe sources (the river, unprotected wells or water catchments) and about 50% came from households that dispose of faecal matter in the bush. Consumption of unsafe river water is a possible cause of diarrhoeal infections and subsequent malnutrition. Mitigating factors include vitamin A supplementation (69%) and measles vaccination coverage (about 93%) attributed to the recent immunization campaigns in Buale and Sakow districts. Nevertheless these are below the SPHERE minimum recommendation of 95%. About 64% of the children came from households reporting to access formal humanitarian support in the preceding three months, mainly in the form of food assistance (about 46%) in February 2006; and informal humanitarian support, mainly in the form of gifts (about 43%). About 0.12% of the assessed population was reported to have night blindness3. On-going humanitarian interventions which may also have mitigated the nutrition situation 1 FSAU Technical Series No. IV 8 FAO classification 3 SPHERE recommends night blindness prevalence of < 1% 2 5 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP include: food assistance by the WFP/WVI, health care services, a water and sanitation program in Buale by the World Vision and supplementary feeding by the African Muslim Aid (AMA). The assessment team recommends: improved access to food (short & long term approaches), health care services; safer water for consumption; and rehabilitation of the malnourished children and women. SUMMARY FINDINGS FOR BUALE SAKOW ASSESSMENT Indicator No. Percentage Under-five children screened during the assessment. Number of boys in the sample Number of girls in the sample Number of households assessed Total population in the assessed households 898 420 478 548 5439 100 46.8 (43.5-50.1) 53.2 (49.9-56.5) 100 100 Global acute malnutrition - Weight For Height Index in Z-Score or presence of oedema Severe acute malnutrition - Weight For Height Index in Z-Score or presence of oedema 197 59 150 21.9(CI:19.3-24.8) 6.6 (CI:5.1-8.4) 16.7 (14.4-19.3) Severe acute malnutrition - Weight For Height in % Median or presence of oedema Proportion of Malnourished pregnant women MUAC<23.0cm N=97 Proportion of severely malnourished pregnant women MUAC<20.7cm N=97 Proportion of Malnourished Non-pregnant women MUAC<23.0cm N=250 39 39 18 8 4.3 (3.1-5.9) 40.2 (30.4-50.7) 18.6 (11.4-27.7) 3.2 (1.4-6.2) Proportion of children from households that consumed ≤ 3 food groups N=898 Proportion of children from households that consumed ≥ 4 food groups N=898 273 626 30.4 (25.4 – 36.5) 69.6 (64.5 – 74.6) Proportion of children with diarrhoea in two weeks prior to the assessment N=898 Proportion of children with ARI in two weeks prior to the assessment. N=898 Proportion of children with suspected malaria in two weeks prior to the assessment. N=898 Proportion of children with Measles in one month prior to the assessment. Proportion of people with suspected night blindness n=5439 Proportion of children supplemented with Vitamin A in six months prior to the assessment. Proportion of children (> 9 months) immunised against Measles. N=873 Proportion of children immunised against Polio N=898 246 128 238 181 66 562 812 816 27.3 (24.5-30.5) 14.3 (12.1-16.8) 26.5 (23.7-29.5) 21.3 (18.7-24.1) 0.12 68.6 (65.3-71.8) 92.5 (91.6-94.6) 90.0 (87.8-92.1) Proportion of children (< 24 months) breastfed less than 6 months N=294 Proportion of children introduced to food before 4 months. N=353 Proportion of children introduced food after 6 months of age N=353 58 121 252 19.7 (15.3-24.7) 18.2 (15.4-21.4) 37.8 (34.2-41.7) Proportion of children from resident households N=898 Proportion of children from displaced households N=898 Proportion of children from returnee/refugee households: N=898 Proportion of children from internal migrant households: N=898 Main source of food Purchases N=895 Humanitarian food assistance N=895 Household own crop production N=895 Main Livelihood: Riverine Proportion of children from HH receiving informal support, mainly gifts Proportion of children from HH receiving formal support (free food aid 45.6%) Main source of drinking water is the river N=898 Proportion of children from HH disposing off Feacal into the bush Crude Mortality Rate CMR (90 days recall period) N=5439 Under-five Mortality Rate (90 days recall period) U5MR N=1669 824 24 46 3 91.6 (89.5-93.3) 2.8 (1.8-4.2) 5.3 (4.0-7.1) 0.3 (0.1-1.1) Global acute malnutrition - Weight For Height Median or presence of oedema 6 530 59.3 (55.9-62.6) 133 15.1 (12.8-17.7) 85 9.9 (8.0-12.1) 442 51.7 (48.3-55.1) 153 15.3 (15.2-20.4) 570 64.5 (60.2-66.7) 426 49.2 (45.8-52.6) 436 50.3 (47.0-53.7) 0.61 (0.39 – 0.83) 1.98 (1.26 – 2.69) Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 1 INTRODUCTION Buale and Sakow districts are located in the Middle Juba Region. Buale district has an estimated population size of 46, 520 and Sakow, 87,935 (WHO, 2005 NIDS figures further verified during the survey team training). The two districts are located along the Juba River. Buale district has five main livelihood zones: the southern inland pastoral (5%), southern east pastoral (15%), southern agropastoral (25%), Southern Juba riverine (50%) and the urban (5%). Sakow district has four livelihood zones: the southern agro-pastoral (45%), Juba pump irrigated riverine (30%), southern inland pastoral (20%) and urban (5%). P! Nutrition Assessment Area Phase Classification 1 Generally Food Secure !P 2 Chronically Food Insecure 3 Acute Food and Livelihood Crisis Nutrition Assessment Area 4 Humanitarian Emergency Livelihood Zones 5 Famine/Humanitarian Catastrophe Juba pump irrigation: Tobacco, onions, maize Early Warning Levels for worsening Phase Alert Southern Agro-Pastoral: Camel, cattle, sorghum Moderate Risk colour of diagonal lines Southern Juba riverine: Maize, sesame, fruits & vegetabl High Risk Lower Juba Agro-Pastoral: Maize & cattle indicates severity Sustained Phase 3, 4 or 5 for > 3 yrs Areas with IDP Concentrations South-East Pastoral: Cattle, sheep & goats Southern inland pastoral: Camel, sheep & goats Sakow is one of the worst affected districts in Middle Juba region from a decade old civil strive and natural calamity. Since 2000, the district has experienced the cumulative effect of drought, poor harvest, reduced pastures and population movement causing deterioration in food security. UN agencies and international non-governmental organisations have been providing humanitarian assistance to the population, but their efforts are often disrupted by insecurity. 7 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 2 BACKGROUND INFORMATION 2.1 Administration: Each of the administration of Buale and Sakow districts is governed by the district council (21 members) which comprises of a district commissioner appointed by the clan elders; a deputy district commissioner and 19 representatives from the clans and sub-clans. The district council, religious leaders and the elders in the district intervene to solve any issues of concern in the districts. 2.2 Security: Sakow is one of the districts in Middle Juba region mostly affected by the 13 years of civil insecurity, drought and floods. Civil insecurity as a result of inter clan fighting persisted until 2005 limiting humanitarian access. The main contentious issue is leadership, which has now been resolved through appointment of the district council. The security situation in Buale and Sakow districts is currently relatively calm. 2.3 Nutrition context In January and March 2006, FSAU conducted two rounds of sentinel sites surveillance mainly among pastoral and agropastoral communities of Buale, Sakow and Afmadow districts. In each of the sites, a minimum of 50 children were assessed. Data from the sites showed high proportions of malnourished children and varying levels of diversity in the assessed households. WarengtakneB/Gadud Tetay Nusduniya Basra Buale 1 fdgp 2 fdgp Sako 3 fdgp Banada Doble Jan06 Mar Jan06 Mar Jan Mar Jan Mar Jan Mar Jan Mar Nevertheless, treatment for severely malnourished children is unavailable in the district; the severely malnourished are referred to MSFBelgium TFC in Marere or Huddur. Jan Mar Proportion of children from households consuming different food groups in sites in Buale, Sako and Afmadow districts 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jan Mar A supplementary (wet) feeding program targeting the malnourished children was and still is managed by Africa Muslim Aid (AMA), in Sakow, Salagle, Banada and parts of Buale and Sakow districts. B/Qoqani Afmadow 4+ fdgp FSAU estimates the long term trend of the nutrition situation in Buale and Sakow districts to be between 15-19.9%. UNICEF/WHO are involved with polio and measles campaigns. 80% Severe 60% Moderate Well 40% 20% W/takne B/Gadud Buale 8 Tetay Nusduniya Basra Sako Banada Jan06 Mar Jan06 Mar Jan06 Mar Jan06 Mar Jan06 Mar Jan06 Mar 0% Jan06 Mar The WVI with support from UNICEF, manages an MCH /OPD together with 38 health posts in Buale. No health facility exists in Sakow district due to insecurity. 100% Distribution of children's nutritional status in sentinel sites in Buale, Sako and Afm adow districts Jan06 Mar 2.4 Health context Doble B/Qoqam Afmadow Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 2.5 Water and environmental sanitation Access to safe water for human and livestock consumption has been a major problem in Buale and Sakow districts, with majority relying on the river as a source. The World Vision is currently involved in a water and sanitation project and currently undertakes irrigation and construction of hand dug wells. Juba Charity Centre is involved in water trucking. 2.6 Education The Social development initiative organization, a local agency in Sakow town is involved in secondary school education and has been operational since March 2006. Additionally, SAWA, a local agency provides adult education services in Buale. 2.7 Food Security Context Following the failure of Gu and Deyr 2005/06 rains, the sorghum crop in most areas never reached maturity while pasture and water scarcity has affected the whole district. According to the FSAU 2005/06 Post Deyr Analysis, Technical Series Report No IV. 8, the Middle Juba region has experienced extremely poor crop production, poor conditions and production of livestock and is faced with a humanitarian emergency with pockets of livelihood crises (refer to map below). The least affected are the camels while cattle and shoats more affected by the drought. As a result of the drought and until the onset of the Gu rains in April 2006, livestock moved within the region in search of pasture and water, limiting the access of households to milk. The cumulative effect of drought, poor harvest over years, high asset depletion, population displacement, and high transportation costs has continuously exposed communities to strains and stresses and undermined their coping strategies. According to the FSAU Integrated food security and humanitarian phase classification shown in the figure below, Buale and Sakow districts is in the Humanitarian emergency with early warning level of moderate risks of famine. Currently, WFP/WVI provides humanitarian food assistance to vulnerable households. 9 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Map 1: Integrated Food Security Phase Classification 10 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 1.1 JUSTIFICATION FOR THE NUTRITION ASSESSMENT The persistent food insecurity in the district has deteriorated due to the prevailing drought condition following the failure of both the Gu and Deyr 2005/06 rains. Consequently, the pastures are depleted and water shortage problems escalated. Hence a nutrition assessment was important to confirm the situation of malnutrition levels. 1.2 ASSESSMENT OBJECTIVES 1. To determine the level of malnutrition and nutritional oedema among children aged 6-59 months or with height/length of 65-109.9cm 2. To determine the level of malnutrition among the women aged 15-49 years in Buale and Sakow districts. 3. To identify some factors influencing nutrition status of the children in the district 4. To determine the prevalence of some common diseases (measles, diarrhoea, malaria, and ARI) in the district. 5. To determine the measles and polio vaccination and Vitamin A supplementation coverage among children in Buale and Sakow districts 6. To assess general feeding and weaning practices in Buale and Sakow districts. 7. To determine the crude and under-five mortality rates in Buale and Sakow districts. 11 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 3 METHODOLOGY 3.1 Sample size The target population was children 6-59 months (or heights between 65cm and 109.9cm). In order to provide valid estimates of the prevalence of malnutrition in children with a 95% confidence level, a total of 898 children were to be examined using 30x30 cluster sampling. 3.2 Sampling methodology A two-stage cluster sampling methodology was used. A list of villages with population estimates for all villages in Buale and Sakow districts was obtained from the WHO, 2005 Somalia polio population estimates (46,520 for Buale and 87,935) for Sakow) records and confirmed by the community members. Cluster selection was done during the training session (See Annex 1). Mortality data was collected from the same clusters. Household sampling was carried out in the cluster, where the first and subsequent households were selected. With the help of assessment guides selected by the local authorities, each team went to the middle of the cluster assigned and determined a random direction by spinning a pencil. The team then moved to the boundary of the cluster following the direction of the pencil. At the boundary of the cluster a pencil was again spun and all households along the direction pointed by the pencil were counted and assigned numbers on a piece of paper. The assessment guide randomly selected the first household to be visited from the number and the subsequent households were selected by moving to the next household in the right hand direction from the household exit (door or gate). If the household did not have an under-five child, teams administered the mortality questionnaire and then moved to the next household in the right hand direction. All eligible children in each household visited were measured. The MUAC of the care giver (a mother or woman aged 15-49 years) was also taken. If a caregiver or child was absent an appointment was made, and the household revisited to examine the child before leaving the cluster. The missing children were noted in the assessment form though no other child specific details were collected. If population from the selected clusters had moved, the team followed them to their new sites and where the population could not be located a cluster with similar charactereristics was used to replace the originally selected cluster. Additional qualitative information was collected using focus group discussions and key informants interviews. 3.3 Quality Control A comprehensive training of enumerators and supervisors was conducted covering interview techniques, sampling procedure, inclusion and exclusion criteria, sources and reduction of errors, taking of measurements, standardisation of questions in the questionnaire, levels of precision required in measurements, diagnosis of oedema and measles, verification of deaths within households, handling of equipment, and general courtesy during the assessment. Pre-testing exercise at the field helped in identifying the enumerators with weaknesses and any question or assessment procedure that was not clear to both supervisors and enumerators. After pre-testing all the mistakes observed were addressed and also the teams’ member composition reviewed on the basis of strengths and weaknesses of the enumerators. Furthermore, supervisors accompanied the enumerators in all households while administering questionnaires and taking measurements to ensure that standard procedures were followed. The coordinators also reviewed all questionnaires for any erroneous information on daily basis. 12 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 3.4 Variables examined Age – Only children aged 6-59 months and whose length/height is 65-109.9cm were selected for examination. The age of a child was determined from the mother/caregiver’s recall, the under fives growth monitoring card, or from a local events calendar (See Annex 2) in instances where date of birth was not stated. Weight: Salter Scale with calibrations of 100g-unit was used. This was adjusted before weighing every child by setting it to zero. The female children would be lightly dressed before having the weight taken while clothes for the male children were removed. Two readings were taken for each child, shouted loudly and the average recorded on the questionnaire. Height: For height, a vertical or horizontal measuring board reading a maximum of 175cm and accurate to 0.1cm was used to take the height or length of a child. The child would stand on the measuring board barefooted; have hands hanging loosely with feet parallel to the body, and heels, buttocks, shoulders and back of the head touching the board. The head would be held comfortably erect with the lower border of the orbit of the eye being in the same horizontal plane as the external canal of the ear. The headpiece of the measuring board was then pushed gently, crushing the hair and making contact with the top of the head. Height/length was then read to the nearest 0.1cm. Two readings were recorded and the computed average used in the analysis. Length: For children aged 6 to 24 months or between 65cm to 84.5cm length instead of height was taken. The child was made to lie flat on the length board. The sliding piece was placed at the edge of the bare feet as the head (with crushing of the hair) touched the other end of the measuring device. Then two readings were taken and the average computed. Arm Circumference: The Mid Upper Arm Circumference was measured using a MUAC tape to the nearest 0.1 cm. Two readings were taken and the average recorded for each child. Women MUAC- Mid Upper Arm Circumference was measured using a MUAC tape to the nearest 0.1 cm. Two readings were taken and the average recorded for each woman aged 18-.49 years. Oedema – Children were examined for the presence of bilateral pedal oedema. The occurrence of pitting as a result of thumb pressure on the foot or leg for 3 seconds was indicative of nutritional oedema. Diarrhoea – Mothers/caregivers were interviewed regarding any episode of three or more loose, watery stools in a day, within the preceding two weeks. Acute Respiratory Infections (ARI) – collected from interviewing the mother/caregiver whether the child had “oof wareen or wareento” (local term of pneumonia) two weeks prior to the assessment. This term was validated by further asking if the child had cough, fever and rapid breathing. Breastfeeding: child having received breast milk within the last 12 hours. Suspected malaria/acute febrile illness: - collected from interviewing the mother/caregiver whether the child had malaria two weeks prior to the assessment. Validated by asking the mother if the child had the following signs; periodic chills/shivering, fever, sweating and sometimes a coma Measles-the child who had more than three of the following signs was considered to have had measles; fever and skin rash, runny nose or red eyes and/or mouth infection, or chest infection. Night blindness- information was collected by asking the respondent to state whether there was any member of the family who has difficult in seeing at night. 13 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Measles immunisation status – the information was obtained by asking the mother if the chid had received measles vaccination and/or confirmed from the child’s vaccination card. Polio immunization- the information was collected by asking the caregiver whether the child (aged 9-59 months) had received polio vaccine or and/or counter checking with chid vaccination card. Vitamin A supplementation - the information was collected from interviewing the mother and recorded child’s the child’s vaccination card. A Sample vitamin A supplement was used to help the mother in identification of Vitamin A. Residential status – In all households visited, the mother/caregiver was asked whether they were originally resident in the village, or if they were displaced from elsewhere. Sex of household head – The mother/caregiver was asked to state the sex of the person who makes decisions regarding welfare of all household members. Feeding – Introduction of breastfeeding and weaning practices and frequency of feeding children was assessed by interviewing mother/caregiver to all children. Dietary diversity -Dietary diversity as household dietary diversity was determined by taking a simple count of various food groups consumed in a given household over the past twenty four hours. Public health facilities- health facilities offering health assistance and usually sponsored by humanitarian organisations, pharmacies and private health services providers Coping strategies- Information on the frequency of using different coping strategies was collected Water access-information on source of water, distance to water points, availability of water container, amount of water used per person per day was sought from the interviewee. Sanitation- interviewer solicited information pertaining to availability and type of toilet, washing of hands after defecation or before food handling and use of soap. MortalityThe overall mortality was calculated by taking the total number of deaths multiplied by a factor (10,000). This was divided by the population of the assessed households using the formulae below: CDR= Number of Death (Total Mid point Population) x Time interval 10,000 Mid Point Population= (Current Population + Population at Beginning) 2 Population at beginning=Current population + Deaths + Number left – Births - Arrivals 14 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 3.5 Description of activities Table 3.1: Chronology of activities for the Buale Sakow Districts Nutrition Assessment Major Activity 2006 Preparation of tools, methodology & review of secondary data (Nairobi) March 1- April 15th, 2006 Resource mobilization; Joint planning meetings with partners (Nairobi April 1-16th, 2006 and Buale Sakow districts Training of enumerators, pre-testing and cluster identification April 22-24th, 2006 Collection of data April 25 – 27th, 2006 Entry of data in Buale April 27th – May 1st, 2006 Preliminary analysis in Buale May 1st- 2nd, 2006 Presentation of preliminary results to the Buale partner agencies May 2nd, 2006 Further data cleaning and analysis May 3rd – 15th, 2006 Report writing May 15- June 12th, 2006 Circulation of first draft report June 13th, 2006 Circulation of the final report July 3rd, 2006 3.6 Assessment team composition Ten teams each consisting of two enumerators and one supervisor conducted the assessment. Each team handled one cluster in a day. An elder from each particular village/cluster assisted the teams in identification of the cluster, its centre and boundary. Supervisors were seconded from the participating partners namely; FSAU and the WVI. The technical coordination was provided by two FSAU senior nutritionists while the logistical support, enumerators and most of the supervisors (mainly WVI staff) were provided by the WVI. Additionally, WFP’s national VAM officer and FSAU’s food security analysts reviewed the food security context. 3.7 Nutrition indicators and cut-offs Weight for height (W/H)- expressed in Z score - is the most appropriate indicator for quantifying wasting in a population during an emergency. Weight for height percent of median compares the weight of the measured child with the median weight of the children of the same height in reference population. MUAC measures the muscle mass help in determining children at risk of death in emergency. During data collection W/H was calculated on the sport and the severely malnourished children referred for treatment. The three modes of expression in the table below were used for presentation of results. Table 3.2 Nutrition Cut-offs Nutritional status Global acute malnutrition Moderate malnutrition Severe acute malnutrition Moderate malnutrition Severe malnutrition Moderate Malnutrition Severe malnutrition WFH in Z-score WFH % of Median < -2 or oedema < 80% or oedema ≥-3 Z-score<-2 ≥-70% and <80% < -3 or oedema < 70% or oedema Pregnant women Nutrition Status Cut offs MUAC<23.0cm MUAC<20.7cm Non-pregnant Women nutrition status MUAC<18.5 cm MUAC<16.0 cm MUAC <12.5 cm <12.5 cm &≥11 cm <11 cm 3.8 Data preparation and analysis During the data collection phase, each questionnaire was thoroughly checked by the field supervisors for omissions, inappropriate responses and for unlikely weight for height measurements. Pre-coded responses were entered into EPI Info windows version for data analysis. Data entry was done concurrently with data collection while addressing any anomalies in the data. Confidence intervals were used to test for significant differences between prevalence of malnutrition among different age, illnesses, dietary diversity and social economic factors. Relationship between variable was taken to be statistically significant if p≤0.05. 15 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 4 THE ASSESSMENT RESULTS 4.1 Household Characteristics of Study Population The nutrition assessment covered a total of 898 children aged 6-59 months and 424 women aged 15-49 years from 548 households. The total number of people in the assessed households was 5432 with a mean household size was 6.049. The household size ranged between 2 to 13 people. The under five population size was 2031 and a mean size of 2.306 per household (SD=0.03). Table 4.1.1: Household Characteristics N % (CI) 6.04 (SD=0.06) 2.3 (SD=0.03) Household size (Mean): Mean No of Under fives Residence status (N=898) Residents Internally displaced Returnees Internal Migrant 823 24 48 3 91.6 (89.6-93.3 2.7 (1.8 – 4.0) 5.3 (4.0-7.1) 0.3 (0.1-1.1) Most (91.6%) of the children from the assessed households were residents4, about 5.3% were returnees; 2.7% were IDPs; and 0.3% were internal migrants. The non residents were mainly from within the Lower Juba region. Overall the non residents had stayed in their current locations for an average of about 9 months. The main reasons for movement were related to water and pasture (46.8%) and food shortage/hunger (38.3%), lack of employment or for civil insecurity. Table 4.1.2: Livelihood Systems No Proportion Confidence Interval (95%) Pastoral Agro pastoral Urban Riverine 5.1-8.6 16.4-21.6 18.5-24.0 48.2-54.9 59 167 187 457 6.7 18.8 21.1 51.6 The main livelihood system in the assessed population was the riverine, as indicated in the chart below. Table 4.1.3: Main source of income The main source of income for the households is crop sales (61.1%), and casual labour (20%). Remittances play an insignificant role since the community is resident with few members to the Diaspora. No Proportion Confidence Interval (95%) Animal & products 103 11.6 9.6-13.9 Crop sales 544 61.1 57.8-64.3 Petty trade 39 4.4 3.2-6.0 Casual labour 178 20.0 17.4-22.8 Salaried employment 25 2.8 1.9-4.2 Remittances 2 0.2 0.0-0.9 4 Residents were taken as those who dwelt in the places of their residences for an extended period or permanently 16 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Water Access and Quality Most of the assessed children came from households that drew water from unprotected water sources like the river (48.4%), or unprotected wells (20.4%). Only about 24.8% of the households relied on water from protected wells. Table 4.1.4: Water Access and Quality A lot of time is spent on water fetching with Main source of drinking water (N=898): about 43.4% River 435 48.4 (45.1-51.8) coming from Protected wells, boreholes or springs 223 24.8 (22.1 – 27.8) households Unprotected wells 183 20.4 (17.8-23.2) taking 30 or Water fetching time (N=898): more minutes to 54.6 (51.2-57.9) 490 < 30 minutes and from the 30.2 (27.2-33.3) 271 30 – 59 minutes water source 13.9 (11.8-16.4) 125 1 – 2 hours including waiting 1.3 (0.7-2.4) 12 > 2 hours time. Number of clean water containers(N=898) Households also 62.5 (59.2-65.4) 561 1 - 2 containers have few and 29.3 (26.4-32.40 263 3 - 4 containers insufficient clean 7.1 (5.6-9.10 64 5 containers water storage and 1.1 (0.6-2.10 10 > 5 containers collecting containers implying that they require frequent trips to fetch water. About 62.5% of the households have only 1-2 containers for fetching or storing water. SPHERE (2004) guidelines recommend a minimum of 2 clean containers of 10-20 litres for water collection alone, in addition to enough storage containers to ensure there is always water in the household. N (%) Sanitation and Hygiene Practices Majority (50.2%) of assessed children came from households that had no access to sanitation facilities and used the bush. Traditional pit latrines (16.4%), improved ventilated pit latrines (24.5%) and open pits (7.7%) were reported as the commonly used sanitation facilities. About 47.8% of the assessed children came form households in which the distance between area of faecal disposal and water source was 30 meters or more as recommended by SPHERE (2004). 17 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Table 4.1.5: Sanitation & Hygiene Sanitation and hygiene Access to Sanitation facility (N=898) VIP latrines Traditional pit latrine Open pit No latrine at all (Bush) Distance from latrine to water source (N=508) < 30meters ≥ 30 meters Washing agent used in the household (N=898) Soap Ash Plant extracts Shampoo None Method of Food Storage (N=898) Suspended in hooks/ropes Put in pots beside fire Put in covered containers Don’t store n % (CI) 220 147 69 451 24.5 (21.7 – 27.5) 16.4 (14.0-19.0) 7.7 (6.1-9.7) 50.2 (46.9-53.5) 265 243 52.2 (47.4-56.6) 47.8 (43.4-52.3) 491 84 299 5 19 54.7 (51.4-58.0) 9.4 (7.6-11.5) 33.3 (30.2-36.5) 0.6 (0.2-1.4) 2.1 (1.3-3.3) 99 292 293 196 11.0 (9.1-13.3) 32.5 (29.5-35.7) 32.6 (29.6-35.8) 21.8 (19.2 (24.7) About 54.7% of the assessed children came from households that used soap for washing; ashes (9.4%); plant extracts (33.3%). About 2.1% came from households that did not use any washing detergent at all. The use of soap or an appropriate hand washing item e.g. plant extracts is a recommended hygiene practice that reduces the chances of ingestion of dirt and/or faecal matter. About 21.8% of the assessed children came from households that did not store any food; and 32.6% from households that stored food in covered containers while 32.5% from households that stored food in pots besides fire. Some 11.0% of the children came from households that suspend their food in ropes/hooks. Safe storage of cooked food (e.g. through covered containers or suspending in ropes/hooks) helps retain cleanness of the food minimizes contamination with insects. Intake of dirty food predisposes one to diarrhoeal diseases, a major cause of malnutrition. Health Seeking Behaviour Table 4.1.6: Health seeking behaviour N Seek healthcare assistance when a member is sick (N=608): Yes No Where (n=506): Private pharmacy/clinic Own medication Public health facility Traditional healer % 506 83.2 (80.0-86.1) 102 16.8 (13.9-20.0) 130 164 103 109 21.4 (18.2-24.9) 27.0 (23.5-30.7) 16.9 (14.1-20.2) 17.9 (15.0-21.3) self-prescription/medication by their caregivers. 18 Majority of the children who fell sick during the two weeks prior to the assessment came from households that used own medication (27%), sought health care assistance from private clinics/pharmacy(21.4%); or sought assistance from public health facilities (16.9%) while the rest visited traditional healers (17.9%) or were administered Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Formal and informal support Table 4.1.7: Formal and informal support About 42.5% of the assessed children came from households that reported having received some informal support during three months prior to assessment. Most of the social support was mainly in the form of gifts (17.8%) and remittances from abroad (9.1%) or from within Somalia (5.0%). About 64% of the assessed children came from households that reported to have received formal support, mainly in form of free food assistance (45.7%), and water subsidy (8.2%). N Informal support (N = 898) Received: Yes No: Type of support (N=257) Zakat from better off households Remittances from abroad Remittances from within Somalia Gifts Loans Formal support (N = 898) Received: Yes No Type of support (N=898) Free food Veterinary care Others (animal transport; water) % (CI) 312 42.5 (29.3-46.9) 516 57.5 (54.1-60.7) 45 82 52 160 43 5.0 (3.7-6.7) 9.1 (7.4-11.3) 5.8 (4.4-7.6) 17.8 (15.4-20.5) 3.5 (3.5-6.5) 575 64.0 (60.8-67.2) 325 36.0 (32.8-39.2) 410 45.7 (42.4-49.0) 31 3.5 (2.4-4.9) 74 8.2 (6.6-10.3) 4.2 Characteristics of the Assessed children A total of 898 children aged 6-59 months and 424 women aged 15-49 were assessed from 548 households. The household size ranged between 2 to 13 people with mean of 6 and standard deviation 1.792. Age and gender distribution of children assessed The summary of the assessed children categorised by age and gender is as presented in Table 2. Out of 898 children examined during the assessment, 420 (46.8%) were boys and 478 (53.2%) were girls, with a sex ratio of 1:1. The ratio of males to females for the 54-59 age category was lowest with the highest ratio recorded at 42-53 age category where the number of boys was almost double that of girls. Table 4.2.1 Distribution of sample by age and sex in Buale and Sakow districts Boys Girls Total Age in months No. % No. % No. 6 – 17 97 10.8 93 10.3 190 18 – 29 129 14.3 162 18.0 291 30– 41 87 9.6 104 11.6 191 42– 53 74 8.2 70 7.8 144 54– 59 33 3.7 49 5.4 82 Total 420 46.8 478 53.2 898 19 % 21.2 32.4 21.3 16.0 9.1 100 Sex ratio 1 : 0.96 1 : 1.26 1: 1.20 1 : 0.95 1: 1.48 1: 1.14 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 4.2 Anthropometric analysis The results of anthropometric analysis were obtained by using weight for height expressed in Z-score or oedema and percentage of the median of the reference population. The table below shows rates of children who were severely, moderately malnourished, normal and the total malnourished. Table 4.2.2 : Distribution of nutrition status Severe Moderate GAM No % No % No 59 6.6 138 15.4 197 (5.1-8.4) (13.1-17.0) % 21.9 (19.3-24.8) Normal No % 701 78.1 (75.2-80.7) The chat indicates a significant shift to the left, in the levels of acute malnutrition. This demonstrates deterioration in nutrition situation. WHZ DISTRIBUTION CURVE 25 Ref erence Sex Combined Frequency 20 15 10 5 W/H Z-Score Table 4.2.3 Distribution of the nutrition status of the children by age Age Groups Severe (<-3z scores Moderate (<-2 - >3 z Normal (> - 2 z score) or oedema) score No. % No. % No. % 6-17 months 12 1.3 36 4.0 142 15.8 18-29 months 30– 41months 42-53 months 54-59 months Total 18 2.0 50 5.6 223 24.8 8 0.9 29 3.2 154 17.1 12 1.3 17 1.9 115 12.8 1 0.1 8 0.9 73 8.1 51 5.7 140 15.6 707 78.7 20 4.75 3.75 2.75 1.75 0.75 -0.25 -1.25 -2.25 -3.25 -4.25 -4.75 0 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP About 21.9% of the assessed children were malnourished, using <-2 Z-score or oedema cut-off while 6.6% of the assessed children were severely malnourished, using <-3 Z-score or oedema cut-off. About 15.3% of the children were moderately malnourished. Eleven cases of oedema were identified in the assessment. The age category 54-59 months had the least number of malnourished children while highest malnutrition was in age category 18-29 months. Table 4.2.4 Distribution of children by nutrition status based on Z-score or oedema by sex Sex Boys Girls Total ≥-2 Z score No. 321 380 701 % 35.7 42.3 78.1 <-2 and ≥-3 Z score No. % 71 7.9 67 7.5 138 15.3 <-3 No. 28 31 59 % 3.1 3.4 6.6 Table 4.2.5 Distribution of children by nutritional status, based on percentage of the Median 6-59 months Age Proportion No 150 Global acute malnutrition 16.7 (CI: 14.4 – 19.3) 111 Moderate malnutrition 12.4 (10.3-14.7) Severe acute malnutrition 4.3 (3.1-5.9) 39 Based on the weight for height as percentage of the median, 16.7.% of the assessed children were malnourished (WHM<80% or oedema) with 4.4% of the children being severely malnourished (WHM<70% or oedema). The distribution of the nutrition status of the children by sex basing from percentage of the median is shown below Table 4.2.6 Distribution of children by nutrition status based on W/H % of median and or oedema by sex Sex Boys Girls Total WHM<70 No. % 16 1.8 23 2.6 39 4.3 <=70WHM>80 No. % 55 6.1 56 6.2 111 12.3 WHM≥80 No. % 349 38.9 399 42.4 748 83.3 The statistical analysis showed no significance difference between the nutrition status of the boys and girls by W/H percent of median indicators. The chronic malnutrition rate based on Height for age, HAZ<-2 was 35.6% (32.5 – 38.9) while underweight rate based on weight for age, WAZ<-2 was 39.9% (CI 36.7-43.26) 4.3 Children malnutrition by MUAC The mid-upper arm circumference of the 502 children aged 12 months and above was taken alongside the height and weight measurements. Basing on the MUAC measurements, 30.6% of the children assessed were malnourished MUAC<12.5cm/oedema with 7.60% of them being severely malnourished MUAC<11.0 cm/oedema. The table below summarizes the results. 21 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Table 4.3.1 Children (aged 12 months and above) malnutrition rates by MUAC Malnutrition Global acute malnutrition MUAC<12.5 cm Moderate malnutrition <12.5 MUAC≥11cm Severe acute malnutrition MUAC<11.0 cm No. 255 Proportion 30.6 (27.6-33.9) 192 23.1 (20.3-26.1) 63 7.6 (5.9-9.6) 4.4 Morbidity, Measles Immunisation, Polio Vaccination and Vitamin A Supplementation Table 4.4.1: Morbidity, measles immunisation, polio vaccination and vitamin A supplementation Incidence of major child illnesses (N=898) ARI within two weeks prior to assessment Diarrhoea within two weeks prior to assessment Malaria (suspected) within two weeks prior to assessment Measles within one month prior to the assessment (N=861) Immunization Coverage (N=906) Children (9-59 months) immunised against measles (N=809) In the past 6 months Before 6 months Not immunized Children who have ever received Polio dose (N= 898) Yes – 1 -2 times – 3 and above No Vitamin A supplementation (N= 898) Children who received Vitamin A supplementation in past 6 months or before Children aged 9 months and above with measles vaccination (n=809) Micronutrients Deficiencies (N=5439) Members with night blindness (n=66) in the assessed households (N=5439): No. %(CI) 128 246 238 190 14.3 (12.1 – 16.8) 27.3 (24.5 – 30.5) 26.5 (23.7 – 29.5) 21.3 (18.7 – 24.1 460 290 59 59.9 (53.4 – 60.3) 35.8 (32.6-39.3 7.3 (5.6 – 9.4) 172 549 79 21.5% (18.7-24.5) 68.6 (65.3-71.8) 9.9 (7.9-12.2) 539 68.6 ((65.3-71.8) 750 92.7 66 0.12 The incidences of ARI (14.3%) and diarrhoea (27.3%) within two weeks prior to the assessment were high but no disease outbreak was reported during the period. About 26.5% had suspected malaria and the incidence of measles among children in the one month prior to the assessment was 21.3%. Measles vaccination coverage for eligible children (9-59 months old) was 92.7%. About 90.1% of the children aged 6-59 months had received at least a dose of polio vaccine. About 68.6% of the surveyed children had received Vitamin A supplementation in the 6 months prior to the assessment. Coverage was relatively high for the three immunizations and supplementation programmes as a result of the recent campaigns by UNICEF, WHO and local partners. 4.5 Vitamin A Deficiency About 0.12% (N=66) of the people from the assessed households(Total HH size=5439) were reported to be faced with night blindness, which is a proxy indicator for vitamin A deficiency. This is within acceptable levels (Sphere). 22 Buale Sakow Districts Nutrition Assessment, April 2006 4.6 FSAU/\WVI/UNICEF/WFP Feeding practices None of the assessed children were exclusively breastfed for the recommended first six months. About two-thirds (62.2%) of the children aged 6-24 months were breastfeeding at the time of the assessment. Of those who had stopped breastfeeding, about 11.7% had stopped breastfeeding before six months of age, 35.9% before their first birthday and the rest (52.3%) within their second year of life. Table 4.6.1: Children feeding practices Children aged 6-24 months (N=294) Is child breastfeeding? Yes No Age stopped breastfeeding (N=524): Never 1 - 5 months 6 - 11 months 12 – 18 months > 18 months Introduction of Complementary feeding 0 - 3 months 4 – 6 months Over 6 months Feeding frequency: Once 2 times 3 – 4 times 5 or mores times 4.7 N % (CI) 58 236 19.7 (15.3-24.7) 80.3 (75.3-84.7) 2 56 218 152 96 0.4 (0.1-1.5) 10.7 (8.2-13.7) 41.6 (37.4-46.0) 29.0 (25.2-33.1) 18.3 (15.2 – 22.0 121 293 252 18.2 (15.4 -21.4 44.0 (40.2-47.9) 37.8 (34.2 – 41.7 39 187 157 45 10 (7.4-13.7) 48.7(43.6-53.8) 39.8 (34.9-44.9) 1.3 (0.3-5.6 About 18.2% of the children aged 6-24 were introduced to foods other than breast milk early in life between the time of birth and the third month of life. Additionally, about 44.0% were introduced to complementary feeding at 4-6 months. About 51% of the assessed children were fed twice or less times a day with mainly cereal-based diets. About 39.8% were fed 3-4 times a day. Dietary Diversity Table 4.7.1: Distribution of dietary diversity among children No of food groups consumed (N=898) 1 food group 2 food groups 3 food groups 4 food groups 5 food groups N 20 181 72 208 417 % (CI) 2.2 (1.4 – 3.5) 20.2 (17.6 – 23.0) 8.0 (6.4-10.0) 23.2 (20.5 – 26.5) 46.2 (38.2 -57.6) Mean HDDS Main source of food (N=898) Purchasing Food Aid Own production Bartering 530 133 90 42 59.3 (56.0 – 62.5) 14.9 (12.6-17.4) 10.1 (8.2-12.3) 4.7 (3.4-6.4) About 30.4% of the children came from households that consumed poorly diversified meal comprising of three or less food groups, while 69.4% came from households consuming four or more food groups in the preceding 24hours prior to the assessment. Households consumed an average (HDDS) of 4.35 food groups (SD=1.8) with the number of food groups consumed ranging from one to 11. Cereal-based diets especially sorghum and maize were the most common. Other food items commonly consumed were sugar (as tea), oil, meat and beans. About 59.3%) of the households surveyed mainly obtained their food through purchasing, 14.9% relied on food aid, 10.1% on their own production and 4.7% relied on bartering. 23 Buale Sakow Districts Nutrition Assessment, April 2006 4.8 FSAU/\WVI/UNICEF/WFP Adult Malnutrition by MUAC Table 4.8.1. Adult nutrition status by MUAC About 40% of pregnant women were 7 2.8 1.1-5.7 malnourished 1 0.4 0.0-2.2 (MUAC<23.0cm) with 8 3.2 1.4-6.2 18.6% severely at risk of 242 96.8 93.8-98.3 malnutrition (MUAC<20.7cm) 18 18.6 11.4 – 27.7 About 3.2% of non21 21.6 13.9 – 31.2 pregnant women (aged 39 40.2 30.4-50.7 15-49 years) were 58 59.8 49.3-69.6 malnourished (MUAC<18.5cm) while 0.3% were at severe risk of malnutrition (MUAC<16.0 cm). n % 95% CI Non Pregnant (N=250) Severe acute malnutrition (MUAC<16.0 cm) Moderate risk (MUAC>=16.0 and <18.0 Global acute malnutrition (MUAC≤18.5) Normal Pregnant women (N=97) Severe Risk (MUAC≤20.7 cm) Moderate Risk (MUAC >20.7 and <23.0 Total at risk (MUAC≤23.0 cm) Normal 4.9 Relationship Between Malnutrition and Other Factors Table 4.9.1: Risk factors and relation to total malnutrition (WHZ<-2) Exposure variable Child sex: n=898 Male Female Age group: 6-24 months 25-59 months Morbidity patterns N (%) Crude RR 95% CI p-value 99 98 23.6 20.5 1.15 0.90 – 1.47 0.30 100 97 25.3 19.3 1.20 1.02 – 1.41 0.04* 23 169 12 88 0.82 0.54 – 1.24 0.409 57 135 24.1 21.5 1.15 0.9 – 1.47 0.31 113 60 21.0 24.5 0.93 0.82 -1.05 0.23 164 28 21.9 14.6 0.91 0.64-1.29 0.67 0.97 0.76-1.26 0.90 0.94 0.66-1.36 0.80 ARI Yes No Diarrhoea: (N=237) Yes No Health programmes Vitamin A Supplement: N=539 Yes No Measles vaccine (N=866) Yes No Dietary & feeding patterns Breastfeeding (N=239) Yes No Dietary diversity ≤ 3 food groups ≥ 4 food groups 50 83 58 139 21.2 70.6 There is significant statistical between acute malnutrition and age group. This may be attributed to poor feeding practices of children and infants. 24 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP QUALITATIVE DATA ON THE FOOD SECURITY SITUATION BUALE DISTRICT Rainfall situation GU rains started in the riverine areas in the south of Buale in the third dekad of March 2006. The riverine areas in the south of Buale include Banta village to Jiilaalow all the way to Anole in the south Buale. The heaviest was received Anole down south up to Jiilaalow. The latest rains fell into Buale town to Buulo-Galool. Though the start of the rains looked below normal in the month of March-April06, a significant improvement was noted in the first one week of May. This replenished water sources and led to regeneration of pasture and vegetation in the agro-pastoral and pastoral livelihoods zones. Crop Condition The poor households do not have inputs especially seeds, having exhausted it during drought period. Poor farmers started to lease away their fields to better off households with plans to share the harvest. Standing crops, mainly sesame and vegetables have been severely attacked by pests (army worms). Unfortunately, these middle and poor households now have little or no seed stock to replant during the rainy season and require assistance to replant the destroyed crops. Food security situation All livelihoods in Buale experienced two consecutive crop failures GU05 and Deyr 05/06 seasons. The food stock is depleted as a result. Currently the cereal prices is high in all areas. For instance one bag of sorghum is currently 250,000 S.Sh for Bu’ale towns market. No local produced cereals available in the market. Few cereals available remained from previously distributed food aid by WFP in collaboration with World Vision. Food sources of poor and middle wealth group of southern agro-pastoral and reverine livelihoods are food aid in almost all areas. The poor wealth group mostly do not have seeds and farmers who managed to plant faced serious pest armyworm attack, hence the need for re-plantation. Most of poor and middle wealth group eat 1-2 times per day. The food comprises mainly of cereal (cooked maize flour locally known as Soor) consumed with wild vegetables such as Ambaqa (refer to the picture). Consumption of Ambaqa is only done during extreme food insecurity. Milk is not available in the market of Buale as camel livestock, which moved to the area during the drought has moved back to their origin and hence and higher prices of it. Income source is limited to few agriculture labour opportunities offered by better off farmers and this is open to clan affiliated poor households. Though the prospect is that the cycle of drought, which hit the area of Buale, is ending, it will take few months’ before the community of Buale fully recover from the effect of the drought. The poor and middle wealthy group continue to depend on food aid before GU harvest scheduled for August 2006. Qualitative information (key informant interview and focus group discussion) indicates that coping strategies implored during the drought are now exhausted and there is a possibility of starvation. 25 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Vulnerability ranking Despite the start of GU in most areas of Buale the effect of drought persists longer due to lack of previous carry over food stocks and lack of cattle milk production attributed to higher culling rate of animals (slaughtering younger calves to save the mother cow). Many weak cattle have died during the onset of the GU rains and due to effect of diseases transmitted by Tse Tse fly. SAKOW DISTRICT Rainfall situation Generally rains started on third dekad of March 2006. Rains fell in all areas except areas starting from Gomir up to Anole near the border with Dinsor district. Water trucking is ongoing in Rakale and Borrow where no rains have been to-date. The area between Baarka and Bohosha received only once for the past 45 days. Generally, the rainfall performance is below normal in the district of Sakow. However, in the first one-week of May 2006, all areas in Juba valley zone including Sakow district received good rains. Crop condition The total acreage of crop is below normal. This is linked to labour migration during the drought to areas outside Sakow and lack of seeds. In the riverine areas, crop planted were limited due to the fear of possible floods. Lack of seeds/farm inputs of the poor and the middle wealth groups led to the abandonment of farms and/or renting it to better off households within the community. Livestock condition An estimated 80% of cattle died for the past two months for drought related factors. The camel condition is normal attributed availability of browsing pasture even during the past Jiilaal dry season. More weak livestock especially cattle died during the onset of the GU rains. Food market prices Current cereals prices are the highest compared to the past two years. 1kg of sorghum costs 11,000 because there is no carried-over stock of the past. Limited amount of food aid is available at the market of Sakow, which according to key informants mainly transported from Salagle with donkey carts. One mitigated factor could be the availability of Camel milk with reasonable prices i.e. 3,000 S.Sh for 1 litre of milk in Sakow town. The prices of livestock are low as the body condition is still weak. For instance, an export quality goat is 200,000 S.Sh while local quality cattle is 1,100,000 S.Sh. The current income sources of the poor households are primarily collection of bush products and few agriculture labour opportunities of the starting GU field preparation and planting exercises. A bundle of firewood of women is 1,000 S.Sh at the market of Sakow while a full donkey cart with firewood ranges between 13,000 S.Sh and 15,000 S.Sh. Food security situation Despite Sakow benefiting from irrigation of Juba river, currently there is no carried forward maize stocks from previous seasons due to the shift of irrigated farmers to fodder production instead of maize grain production after two consecutive rain failures hit in all agro-pastoral and pastoral areas of Sakow district. Two early consecutive (Deyr 04/05 and GU06) seasons of non-food cash crop production e.g. sesame also contributed the early depletion of food stocks within the districts. Food consumption varies by livelihoods and by wealthy groups. The body condition of the remaining cattle is improving. Remittance is very limited in the area of Sakow as the community here did not flee the homeland for the past 15 years and therefore majority do not have relatives in Diaspora. All poor & middle wealth groups 26 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP do not have stocks at the moment and mainly depend on purchase of what remained from cereal food aid distributed in March 2006 by WFP especially the late food aid being distributed in Salagle. No major disease outbreak is reported in Sakow. However, due to lack of provision of health services and according to discussion with the community there is high prevalence of certain diseases such as malaria, diarrhoea, dysentery, and conjunctivitis. Schools have been closed in the district due to high dropout attributed to the drought. Majority of the poor and middle wealth group of all livelihoods eat 1-2 meals per days composed of mainly cereals with hardly additives. No diversity foods available and fish is not available in Desheks as it was dry and just refilled by the current onset of GU rains. There are limited agricultural labour opportunities not open to everybody, but rather based on clan or relative affiliation. The vulnerability ranking Though, the drought effect has been felt across all livelihoods in the district, the Southern agropastorals and riverine livelihoods groups are most vulnerable in the Sakow district due to depleted household stocks during the successive rain failures. 27 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 4.10 MORTALITY The retrospective mortality assessment was done co-currently with the nutrition assessment in 30 selected clusters. All households in the selected clusters were eligible for the administration of the mortality questionnaire irrespective of whether or not they had under-five. A total of 927 households were assessed and the retrospective mortality rates calculated on the basis of recall period of 93 days from January 23rd, 2006 – April 24th, 2006. Data was entered in Epi info and mortality rates calculated using the formulae below. i). Crude mortality rate (CMR) CMR= Number of Death (Total Mid point Population) x Time interval 10,000 Mid Point Population= (Current Population + Population at Beginning) 2 Population at beginning=Current population + Deaths + Number left – Births - Arrivals Number of deaths=29 Current Population=5083 Number of those arrived (Arrivals) =6 Number that left= 202 Number of Births=61 Time interval=93 days CMR =0.61 deaths/10,000 persons/day (CI: 0.39 – 0.83). Basing from the WHO categorization, the CMR of Buale Sakow districts is within acceptable levels. ii). The Under five mortality rate (U5MR) U5MR= Number of Death of under-five (Mid point population of under-five) x Time interval Mid point population of under-five= Current population of under-five+ Population of under-five at beginning 2 Population at beginning of recall = (population present + left + deaths) – (joined + births) Number of death of under-five=29 Current population of under-five=1589 Number of under-five that left=16 Number of Births=61 Time interval= 93 days Number of under-five that arrived=6 U5MR=1.98/10,000/day (CI:1.26 – 2.69) Basing from the WHO classification, the U5MR of Buale Sakow of approximately 1.53 deaths/ 10,000 persons per day indicates an acceptable situation. The main causes of deaths were diarrhoeal diseases: 2.0% (17 cases), malaria: 1.2% (10 cases), birth complications: 0.8% (7 cases) and to HIV/Aids 0.6% (5 cases) to HIV/Aids. Other causes of death reported included measles and ARI. 28 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 5 DISCUSSION AND CONCLUSIONS Nutrition Status Findings indicate a global acute malnutrition rate (weight for height <-2 Z score or oedema) of 21.9% (CI:19.3-24.8) and severe acute malnutrition (weight for height <-3 Z score or oedema) of 6.6% (CI:5.18.4). This highlights a critical nutrition situation (WHO) which is worsening when compared to long term estimates of malnutrition (15-19.9%) for the area. Additionally, about 40% of the 97 assessed pregnant women had MUAC < 23.0 cm, while 3% of the 250 non-pregnant women had MUAC <18.5cm and were categorized as malnourished. Retrospective Mortality The crude mortality rate was 0.61 (CI: 0.39 – 0.83) deaths/10,000/day and the under five mortality rate 1.98 (CI:1.26 – 2.69) deaths/10,000/day which are acceptable (WHO categorization). Child care related issues About 38% of the children were introduced to complementary foods at the age of 6 months which is the recommended age. Thus, majority of the children (about 62%) were introduced to foods either early or later in life, a sub-optimal feeding practice that could lead to poor nutrition situation. About 51% of the assessed children were fed twice or less times a day with mainly cereal-based diets which is also a suboptimal practice (a minimum of 4 feeds that are diverse in nutrients is recommended). There was a statistical significance (p<0.04) between malnutrition and the age group with the 6-24 months category being more likely to be malnourished. This is usually the critical and vulnerable age among the under fives at which children are breastfed and introduced to other complementary foods. Sub-optimal feeding practices like inadequate breastfeeding practices, less frequent feeds as well as poor quality of the foods negatively impact on the nutrition status of the children. The relatively high measles immunisation and vitamin A supplementation coverage serves as good mitigating factor to a poor nutrition situation and is associated with a recent measles immunisation campaigns. Morbidity Diseases and children’s nutritional status exhibit a vicious cycle relationship. Sick children will usually suffer anorexia reducing food intake while food absorption is also compromised ultimately predisposing the children to poor nutrition. Likewise, malnourished children are more prone to diseases as their body’s immune system is low. About 49% of the assessed children reported to have suffered from an episode of a communicable disease in the preceding two weeks. The high morbidity may be associated both to endemic diseases and limited access to health care services, particularly in Sakow where there is not a single health facility. The prevalence of diarrhoea (27%) and malaria (26%) in the two weeks prior to the assessment were particularly high and may have contributed to the critical nutrition situation. Additionally, about 75% of the children came from households which consumed water from unsafe sources (the river, unprotected wells or water catchments) and about 50% came from households that dispose off faecal matter in the bush. Consumption of unsafe river water is a possible cause of diarrhoeal infections and subsequent malnutrition. Dietary diversity About 30.4% of the children came from households that had consumed meals from three or less food groups (based on FAO classification), while about 69.6% came from households consuming a more diverse diet of four or more food groups in the previous 24 hours. Cereal based diets especially sorghum and maize were the most common. Other food items commonly consumed were sugar and oil. 29 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Previous studies have indicated an association between malnutrition and dietary diversity. A significant proportion of children consumed a less diverse diet of less than four food groups in this study, which could have contributed to acute malnutrition. Qualitative Data Qualitative data indicates poor household food access due to high food prices, and general unavailability of animal products, most of the livestock having either died, migrated back to areas of origin or, in too poor body condition to provide milk and milk products. The food stocks are also exhausted and the population groups coping strategies have almost collapsed. Limited access to food may have contributed to poor dietary intake and subsequently acute malnutrition. Mitigating Factors Mitigating factors include vitamin A supplementation (69%) and measles vaccination coverage (about 93%) attributed to the recent immunization campaigns in Buale and Sakow districts. Nevertheless these are below the SPHERE minimum recommendation of 95%. About 64% of the children came from households accessing formal humanitarian support in the preceding three months, mainly in the form of food assistance (about 46%) in February 2006; and informal humanitarian support, mainly in the form of gifts (about 43%). On-going humanitarian interventions which may also have mitigated the nutrition situation include: food assistance by the WFP/WVI, health care services and a water and sanitation program in Buale by the World Vision and supplementary feeding by the African Muslim Aid (AMA). 6 CONCLUSION AND RECOMMENDATIONS The global acute malnutrition (weight for height <-2 Z scores or oedema) of 21.9% depicts a critical nutrition situation in Buale and Sakow districts. Limited access to food, high morbidity and poor child care practices are among the underlying factors contributing to the critical nutrition situation. The crude mortality rate of 0.61/10,000/day and the under five mortality rate of 1.98/10,000/day are however within acceptable levels (WHO categorization). Following presentation and discussion of assessment findings with partners, the following recommendations were made: Short term recommendations: i) Increased access to food (both the short and longer term interventions). ii) Continuation and intensification of health, water and sanitation interventions especially immunization programs, rehabilitation and protection of water points and provision of sanitary facilities iii) Rehabilitation of cases with severe malnutrition. Long-term Recommendations i) As high levels of malnutrition have been seen throughout the camps, it is recommended that the local MCHs / local health personnel are equipped with the knowledge and skills to manage severe malnutrition both during and outside periods of crisis. ii) Improve access to quality for medical care through establishment of a clinic or hospital in Buale Sakow districts. iii) Health/nutrition education for the population focusing especially on appropriate child feeding practices and management of diarrhoeal diseases. iv) Establish projects geared towards livelihood recovery 7 APPENDICES 30 Buale Sakow Districts Nutrition Assessment, April 2006 7.1 FSAU/\WVI/UNICEF/WFP APPENDIX 1: Population Estimate for Buale and Sakow Districts S.# Village/Town 1 Buale 2 Gobate 3 Sukeyla 4 Qardhale 5 Canole 6 J.Kore 7 Dal-la-helay 8 Dalxis 9 Sakow 10 Arbay 11 Nebsoy 12 Birbiriso 13 Gurmayso 14 Dodey 1 15 Bar M Dhorow 16 Nusduniya 17 Kurawo 18 Sako Yare 19 Qayd Cajuz 20 Basra 21 Qaboobe Population Cumulative 7500 1550 810 635 900 605 600 450 13050 12000 725 750 750 1800 400 1500 1000 700 700 900 800 400 Clusters 7500 1,2,3,4 9050 10460 11970 14035 15590 16790 18840 5 6 7 8 9 10 11 32040 12,13,14,15,16,17,18 32765 33815 36215 38345 39295 41695 42695 44740 46080 48080 49480 51230 19 20 21 22 23 24 25 26 27 28 29 30 Inaccessible areas due to sludgy or muddy roads – omitted from the sampling frame 1 Qararey 545 2 Bidi 435 3 Afgoye 455 4 Kaskey 445 4 Farbito 1000 5 Manane 645 6 Shingani 710 7 Hurufle 600 8 Arabow 400 9 Kurtun 400 10 Kafinge 490 11 Qoryale 500 12 Bilweyn 200 13 Raxole 845 14 Waregta Hose 505 22 Gomir 15 Jirmo 300 23 Bagaday 16 Cilmi 600 24 Ashirow Lizan 17 Markanbka 300 25 banada 18 Booho 250 26 Aliyow kerow 19 Bulo Idow 600 27 Galagal onle 20 Somba 250 28 Gololey 21 A.Arbow 950 31 1200 605 485 3000 400 2500 800 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Table of Random Numbers Range: 1 to 500, Number: 500 449 77 225 383 382 371 436 213 239 104 92 171 96 346 41 313 422 406 317 194 363 221 283 128 201 329 202 417 375 146 55 349 222 325 291 75 413 100 210 265 102 403 73 111 320 488 71 190 17 367 33 158 308 306 343 65 57 172 432 229 390 43 16 152 58 388 3 126 29 386 129 442 334 276 293 36 438 18 354 214 116 46 255 347 286 94 297 141 258 472 441 464 471 105 327 127 169 189 323 1 12 500 163 256 372 4 421 439 282 101 233 123 238 167 208 315 136 285 30 211 322 395 414 416 348 67 338 84 145 212 186 254 103 199 69 85 341 358 493 132 115 326 498 480 443 474 384 19 164 40 451 122 324 402 5 461 391 356 68 381 278 277 463 309 7 462 468 424 409 264 453 430 447 419 230 64 114 339 396 379 290 300 301 466 244 407 260 467 305 302 287 359 20 34 374 487 150 392 385 311 44 227 87 477 98 316 32 165 236 109 215 35 262 331 134 458 271 196 70 61 292 247 184 117 364 249 8 51 427 270 246 484 232 151 295 353 481 181 237 119 437 179 82 137 83 166 162 465 445 120 252 216 32 133 180 378 263 121 235 205 337 131 429 272 62 248 494 380 174 482 446 191 456 342 118 350 408 361 469 78 23 22 38 154 81 360 2 435 352 91 399 479 476 59 95 410 431 304 434 149 60 280 310 47 142 365 444 52 31 90 269 333 412 448 147 9 257 321 14 124 450 267 206 72 377 195 204 397 155 401 426 398 387 99 177 294 176 440 273 261 298 159 489 45 420 63 373 170 423 303 499 259 217 107 288 470 319 130 318 351 289 153 454 66 56 108 345 27 281 6 241 335 279 433 425 376 460 240 54 457 28 224 97 340 148 21 495 168 485 187 188 37 203 268 157 25 231 459 220 135 428 125 110 219 182 76 266 86 490 250 197 491 366 389 193 207 49 173 452 415 483 330 80 492 89 251 13 113 234 53 24 218 144 226 393 198 161 139 370 473 50 253 175 209 357 400 362 10 183 314 418 478 369 275 411 15 336 200 296 223 404 475 368 284 497 74 496 143 332 112 486 245 355 455 242 42 185 228 178 140 160 79 26 328 344 243 312 405 394 192 39 274 11 156 88 299 138 307 106 48 Buale Sakow Districts Nutrition Assessment, April 2006 7.2 APPENDIX 2: Traditional Calendar Districts 2001 2002 52 January Carafo 51 February Sakow March April May FSAU/\WVI/UNICEF/WFP For Nutrition Assessment In Buale And Sakow 2003 40 Carafo 39 Sakow 50 Safan 49 Mawlid RabiculAkwal 38 Safar 37 Mawlid Rabicul Awal 48 Malmodone RabiculAkhir 36 Iraq War Malmodone Rabicul Akhir 35 Jamadul Awal 34 Death of General Gabyoo June 59 Jamadil Awal 47 Jamdul Awal July 58 Jamadil Akmir 46 RRA fighting in Baidoa -jamadul Akhir 33 Rajab 32 Shacban 57 Rajab 56 September 11 Shacban 45 Rajab 44 Shacban October 55 Soon 43 Soon 31 Soon Death of former Buale DC November 54 Soonfur 30 Soonfur December 53 Sidataal 42 Buale Fighting -Soonfur 41 Sidataal August September 29 Sidataal 33 2004 28 Carafo 27 Sakow Sakow market burnt 26 Safar 25 Mawlid Rabicul Awal 24 Malmo=done Rabicul Akhir 23 Jamadul Awal 22 Jamadul Akhir 21 Rajab 20 Shacban -World Vision moved from Buale - Buale reconciliation meeting 19 Election of Somali President Abdulahi Yusuf 18 Good deyr rain Soonfur 17 Sidataal 2005 16 Carafo 15 Sakow 14 Safar 13 Riverine floods - Mawlid Rabicul Awal 12 Rabicol Awal Malmodone 11 Jamadul Awal 10 Jamadul Akhir 9 Rajab 8 Shacban 7 1st food distribution by WV 6 Soonfur Buale Sakow Districts Nutrition Assessment, April 2006 7.3 FSAU/\WVI/UNICEF/WFP APPENDIX 3: Mortality Questionnaire Household No: _____ No. 1: First Name Date: _______ Team No: ____ Cluster No: ____ Enumerator’s Name: ____________ 2: Sex 6: Reason for 7: Cause of 3: Age 4: Born since 21st 5: Arrived since (1=M; October 2005 21st October leaving death (yrs) 2=F) 2005 a) How many members are present in this household now? List them. b) How many members have left this household (out migrants) since 1st June 2005? List them c) Do you have any member of the household who has died since 1st June 2005? List them Codes Reason for migration 1= Civil Insecurity 2= Food Insecurity 3= Employment 4=Divorce 5=Visiting Cause of death 6= Other, specify 1= Diarrhoeal diseases 2= ARI 3= Measles 4= Malaria 5= HIV/AIDS 6= Anaemia 7= Birth complications 8= Other, specify Summary* Total Current HH Members Arrivals during the Recall period Number who have left during Recall period Births during recall Deaths during recall period * For Supervisor Only 34 U5 7.4 APPENDIX 4a : Nutrition Assessment Questionnaire Somali version Tariikh_________________ Lambarka Kooxda__________ Lambarka Goobta___________ Magaca Kormeeraha______________________ Magaca Degmada_____________ Magaca Tuulada/Magalada____________ Magaca Qaybta______________ Lambarka Qoyska______________ S1-14 Dabeecadaha Qoyska S1 S2 S3 S4 S5 S6 S7 Muxuu yahay jinsiga madaxa qoysku? 1= L 2= Dh Imisa qof ayaa qoysku ka kooban yahay ( tirada xubnaha qoyska)? ______ Imisa Carruur 5 sano ka yar ayaa u jooga qoyska ( Tirada 5 sano ka yar) ______ Xaaladda Degannaanta qoysku waa noocee? 1 = Degaan joogto ah 2= Gudaha ku barakacay 3= Soo laabtay 4= Gudaha ka soo hayaamay 5 = Nooc kale, caddee Intaadan halkan degin xaggee awal ka timid? ( Degaankaaga asalka ah Halkan imisaad ku noolayd? _______ Maxay ahayd sababtaad halkan u timid? _______ ( waxaad xulan kartaa in kabadan hal mid haddii ay habboontahay 1= Amnaan darro 2= Shaqo la’aan 3= Cuntoyari 4 Biyo yari S8 Shayga ugu muhiimsan ee noloshiinu ku tiirsan tahay waa kuma? 1) Xoolo 2) Beero-xolaleey 3) Xoogsi 4 ) Beeraha waraabka, 5 ) Ganacagsi yar yar , 6) Mush,haari ah, 7) iibka dalaga, 8) iibka Xoolaha iyo wax soo saarka xoolaha 9) xawaalad/Sadaqo 10 ) Nooc kale; caddee-----------------------S 9-11 Kaladuwanaanta cuntoyinka (Dietary Diversity) Xusuusashada cuntadii qoysku isticmaalay 24kii saac ee tagtay. Waraystuhu waa inuu caddeeyo in shalay ay caadi`u ahayd qoyska iyo inkale. Hadii ay jireen Alle-bari (Walimo), Duug ama xubnaha inta badani maqnaayeen, kolka maalin kale waa in la doorta sida dorraad. Ama beddelkeed dooro qoys kale S9 Rashin nocee ayay isticmaleen dadka qoyska tirsan ka bilabato marka la soo kacay shallay subax? Imisa jeer ayay rashinka cuneen dadka qoyskan katirsan? (kudar isticmalka cabitaan iyo caannaha naaska) 0=maya 1= mar 2= laba 3=3 saddex 4=4 jeer 5=5 ama in kabadan Nooca da Cuntada Inta jeer (<5yrs) 1. 2. 3 4 5 6 Inta jeer >5yrs Tirade guud ee noocyada cuntada iyo kooxaha la isticmaalay S-10 iyo 11{Waxaa buuxinaya kormeeraha } 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Firaley (Bariis, Qamadi, Basto, Badar, Gelley, Canjero, Bur) Digirta iyo qolofleyda kale Caano(milk) Kalluun/cunto badeed Hilib iyo ukun Sokorta Shaaha iyo tan kaleba Dufan/Saliid/Subag Xididaley/buruqley( Bataati Miro Khudaar 7 S 10-Tirade noocyada cuntada ? S11 TIirada kooxaha cuntada ? Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP S12. Intabadan rashinka laga isticmalay guriga intuu inka soo gallay? 1=Xoolaha/dhalaga beerta 2=Soo iibsasho 5=ku doorsasho 6=Amaah 7=Qaraan 8=kuwa kale (caddee) ________________ 3=Siismo saxiib/qarabo 4=Raashin gargaar ah S13-23 Cudurrada, Quudinta & xaaladda tallaal ee ilmaha jira 6 -59 bilood ( ama 65-110 cm) dherer le’eg ee jooga guriga Tirsi Magac S13 Shuban 2dii Usbuuc ee tagtay S14 Ofwaren 2-dii usbuuc ee tagtay S15 Duumo 2-dii Usbuuc ee tagtay? S16 (9-59 Billood) Jadeeco bishii tagtay? S17 (9-59 S18 S19 S20 Billood) Lixdii bilod ee tagtay mala siiyey Vit A ? ( tus kabsol-ka) Ilmaha Naasaha ma nuujisaa hada Haddii aanu naasaha nuugin imisuu jirey marki laga guriyey/gooyey? Ma laga tallaalay Jadeeco 1= Haa 0= Maya 1=Haa 0=Maya 1=Haa 0=Maya 1=Haa 0=Maya 1=Haa 0= Maya 1=Haa 0=Maya 1=Haa 0=Maya 1= ka yar 6 bilod 2= 6 – 11 bilood 3=12 – 18 bilood 4=18 bilood ama ka badan 5= Weligii lama siin S21 Imisuu jirey ilmuhu markii la siiyey cunto iyo cabbid aan ahayn caanaha naaska? 1=0-3 bilood 2=4-6 bilood 3=7 bilood ama ka badan S22 Malinti imisa jeer ayaad quudisa ilmaha? 1= Mar 2= Laba 3= 3-4 jeer 4= 5 ama ka badan S23 Weligi inte goor tallaalka dabaysha afka laga siiyey 1=1-2 jeer 2=3 & kabadan 3=Marna 1 2 3 S24 S25 majiro Marki ilmuhu kaa jirrado, halkee gargaar caafimaad ka raadsataa? 1-Dawo dhaqameed 2=Bar caafimad gaar loo leyahay/Farmashi 3= Baraha caafimaadka bulshada 4= Meel kale, caddee 5=Ma xanunsan Ma jiraa qof dadka qoyska ka mid ah oo araggiisu liito habeenkii ama fiidki iyadoo dadka kale caadi wax u arki karaan? 1 = Haa 2-6 Sano= 2=haa ka badan 6 Sano S26 – 33 jir cabbirka ilmaha jira 6- 59 bilod ( ama 65-110cm) ee qoyska ka mid ah 36 3=Mayo Buale Sakow Districts Nutrition Assessment, April 2006 Tirsi Magaca Kowaad S26 Jinsi 1= (L) 2=(Dh) S27 Da’da oo’ bilo ah FSAU/\WVI/UNICEF/WFP S28 Barar S29 Dhererka (cm) S30 Culayska (kg) 1=Haa 0= Maya S31 Dhexroork a Bartamaha Cududda Sare (MUAC) (cm) S32 Dhereka Bartamaha \Cududa MUAC {Cm} S33 Xaalada \Daryeellaha 12- 1 2 3 37 Uurey Uur Lahayn Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP S 34. Isticmaalka xeeladaha isdebiridda (Consumption Coping Strategies) Soo noqnoqodka isticmalka 0= Marna Lama isticmalin (0 jeer usbuuciiba ) 1= Mar dhif ah(< 1 mar usbuuciiba) 2= Marmar ( 1-2 jeer usbuuciiba ) 3= Inta badan (3-6 jeer usbuuciiba) 4= Markasta( Maalin walba) S34 30 Kii casho ee tagtay haddi ay jirtey xilli aydaan haysan lacag aad ku iibsataan ama raashin idinku filan inta badan maxaa la samayn jirey a) b) c) d) e) f) g) h) i) j) k) l) m) n) In laga tago cuntada tayada leh lana isticmaalo cunto jaban oo tayadeedu lidato In cunto la soo deynto ama lagu xirnaado kalmo laga helo saaxiibo ama qaraabo Cuntada in deyn lagu soo qaato Duurka in qaraabasho ama ugaarsi loo doonto Xoolaha in lagu iibsado qiimo xooris ah si raashin loogu beddesho Xubnaha qoyska in loo diro inay meelo kale wax ka soo cunaan Xubnaha qoyska in tuugsi loo diro In la yareeyo xaddiga cuntadii la karsan jirey markiiba Cuntada dadka waaweyn in laga xannibo si ilmaha cuntada loogu quudiyo Raashin diyaarsan in suuqa laga soo gato In la yareeyo intii jeer maalinti wax la cuni jirey Maalin dhan inaan dab la shidan In la baabi’iyo hantida si raashin loo helo : in la gado Xoolo, Dhul ama dahab in hantida dammaanad ahaan loo isticmaalo sida Berkad ama Dahab si raashin loo helo Q35 - 40 Helitaanka Biyaha Aadamigu isticmaalo (Tayo ahaan iyo tiro ahaan - quality and quantity) S 35 Isha ugu muhmsan ee biyaha la cabbo 1= tuubo guriga toos u keenta biyo 2= Qasabadaha dadweynaha ka dhaxeeya 3= tubo ceel hoos u qodan 4= Ceel lama il burqanaysa oo la xafiday 5= Ceel am il aan la xafidin 7 webi 8= kale S36 isha ugu muhimsan ee biyaha karinta iyo nadaafadda jirka 1= tuubbo guriga toos u keento biyo 2= qasabadaha dadweynaha ka dhaxeeya 3 Tubo ceel hoos u qodan 4 il burqanaysa ama ceel la xafiday 5 biyo roob 6 il iyo ceel aan xafidnayn 7 wax kale cadee-----------------------------S 37 Biyaha qoysku maalintii u isticmalo cabid, karsi iyo nadaafadda dadka 1= <20 litir 2= 20-60 litir 3= 60-120 litir 4= >120 litir S38 Masaafada barta biyaha ee ugu dhow 1= 0-500 tallaabo 2= 501-1000 tallaabo 3= 1001-5000 talaabo 4= ka badan 5000 tallaabo S39 Biyaha iyo habka lagu helaba waa la ilaaliyey si joogto ah sidaas darteedna waa la heli karaa intii looga baahnaa 1= Marna 2= marmar 3= inta badan mar kasta 4 =Mar kasta S40Tirada weelasha biyaha si nadiif ah loogu kaydsado ee qaada 20 litir 1= 1-2 Caag 2= 3-4 Caag 3= 4-5 Caag 4= ka badan 5= Caag S41-47 Fayadhawrka iyo Nadaafadda ( u sahlanaanta iyo tayada - access and quality) S41 Nooca Musqusha xubnaha qoyska inta badani isticmalan 1=Musqul god leh oo habaysan( saxan leh) 2= Musqul caadi ah 3= God af bannaan 4= Bannaanka 5= Wax kale ( tilmaan) S42Tirada dadka halkii musqul isticmaasha 1=1-5 2= 6-10 3= 11-15 4= 16-20 5= ka badan 20 qof 6= kuma haboona S43 Dadka gurigu markay saxaroodaan ka dib faraha ma dhaqdaan 1= Mar kasta 2= inta badan 3= marmar 4= Dhif iyo nadir S44 Dadka gurigu ma gacmo dhaqdaan intaan wax la cunin ama xilliga diyaarinta cuntada 1=badanaa 2= inta badan 3 =marmar 4= dhif iyo nadir S45 Qoyska miyu haysta sabuun? 1=Haa 0=Maya S46 Xubnaha qoyska ma isticmalan sabuun ay ku gacma dh’aqdaan sharada kadiib ii goorta rashinka ladiyarinayo? 1 =Haa S47 Masaafada ay isu jiran musqusha iyo isha biyaha 4= 21-29 talaabo 5= 30 tallaabo iyo ka badan 1= 0-5 tallaabo 2= 6-10 tallaabo 38 3= 11-20 tallaabo 0= Maya Buale Sakow Districts Nutrition Assessment, April 2006 7.5 FSAU/\WVI/UNICEF/WFP Appendix 4b: BUALE AND SAKOW NUTRITION ASSESSMENT QUESTIONNAIRE-English version BUALE/SAKO DISTRICTS NUTRITION ASSESSMENT, APRIL 2006 HOUSEHOLD QUESTIONNAIRE Date_______________ Team Number ______ Cluster Number _______________________ Name District ____________________ Household Number ______ Name of enumerator __________________ Name of Village/Town ______________________ of the Respondent _______________ Q1-8 Characteristics of Household Q1 How many people live in this household (Household size)5 ?__________ Q2 How many children are below five years in this household (Number of < 5 years)? ____________ 1= Resident6 Q3 What is your present household residence status? __________ If answer to the above is 1, then move to Question 7. 2=Internally displaced7 3=Returnees8 4=Internal immigrant9 5=Other (specify) Q4 Place of origin (categorize during questionnaire design) __________________ Q5 Duration of stay ______________________ Q6 Reason for movement: 1= Insecurity 2=Lack of jobs Q7 What is the livelihood systems used by this household? 1= Pastoral Q8 What is the household’s main source of income? 3= Food shortage 4=Water shortage 5=Others; specify_______________________ 2=Agro- pastoral 4= Riverine (irrigated agriculture; fishing) 1= Animal & animal product sales 5= Salaried employment 3=Urban 2= Crop sales 6= Remittances 3= Petty trade 4= Casual labour 7= Other, specify ____________________ Q9-16 Feeding and immunization status of children aged 6 – 59 months (or 65 – 109.9 cm) in the household. 5 Number of persons who live together and eat from the same pot at the time of assessment A person who dwells in a particular place permanently or for an extended period 7 A person or groups of persons who have been forced or obliged to flee o to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights, or natural or human-made disasters, and who have not crossed an internationally recognized State Border" source, guiding principles on internal displacement 8 Refugees who have returned to their country (Somalia) or community of origin, Somalia, either spontaneously or through organized repatriation [ UNHCR definition] 9 A person who moves (more or less permanently) to a different administrative territory due to a wide range of reasons (e.g. job related, security) 6 39 Buale Sakow Districts Nutrition Assessment, April 2006 Sn o First Name Q9 (If 6-24 months) Are you breastfeeding 10 the child? (if no, skip to Q14) 1=Yes 2=No FSAU/\WVI/UNICEF/WFP Q10 Q11 Q12 If breast feeding, how many times/day? If not breast feeding, how old was the child when you stopped breast-feeding? At what age was child given water/ foods other than breast milk 1=<3 times 2=3-6 3=On demand 1=<6 months 2=6-11 months 3=12 – 18 months 4=≥18 months 5= Never breastfed Q13 How many times do you feed the child in a day (besides breast milk)? 1= Once 2= Twice 3= 3-4 times 4= 5 or more times 1=0-3 months 2=4-5 months 3=6 months or more. 1 2 3 4 Q17-27 Anthropometry and morbidity for children aged 6 – 59 months or (65 – 109.9cm) in the household 10 Child having received breast milk either directly from the mothers or wet nurse breast within the last 12 hours 40 Q 14 Has child been provided with Vitamin A in the last 6 months (show sample) 1=Yes 2=No Q15 (If ≥9 months old) Has child been Vaccinated against measles? 1=In past 6 months 2=Before 6 months 3=None Q16 How many times has the child ever been given polio vaccine orally 1=1-2 times 2=3 and above 3=Never Buale Sakow Districts Nutrition Assessment, April 2006 Sno FSAU/\WVI/UNICEF/WFP Q17 Q18 Q19 Q20 Q21 Q22 Child Sex Age in months Oedema Height (cm) Weight (kg) MUAC (cm) First Name As per table on page 1 1=Male 2=Femal e Q23 Diarrhoea11 in last two weeks Q24 Serious ARI12 in the last two weeks 1=yes 2=no 1=Yes 2=No 1= Yes 2= No Q25 Febrile illness/ suspecte d Malaria13 in the last two weeks 1=Yes 2=No Q26 (If ≥9 month) Suspected Measles14 in last one month 1=Yes 2=No Q27 [Applicable for a child who suffered any of the diseases in Q23 – 25 Where did you seek healthcare assistance when (Name of child) was sick? 1=No assistance sought 2=Own medication 3=Traditional healer 4=Private clinic/ Pharmacy 5= Public health facility 1 2 3 4 28: Anthropometry (MUAC) for adult women of childbearing age (15-49 years) present at the household Sno Name 1 Mother: Age (years) MUAC Physiological status 1=Pregnant 2=Non pregnant Illness in last 14 days? If yes, what illness? 2 3 Q29 Does any member of the household have difficulty seeing at night or in the evening when other people do not? 1= 2- <6 years 2= ≥ 6 years 3= None 11 Diarrhoea is defined for a child having three or more loose or watery stools per day ARI asked as oof wareen or wareento. The three signs asked for are cough, rapid breathing and fever 13 Suspected malaria/acute febrile illness: - the three signs to be looked for are periodic chills/shivering, fever, sweating and sometimes a coma 14 Measles (Jadeeco): a child with more than three of these signs– fever and, skin rash, runny nose or red eyes, and/or mouth infection, or chest infection 12 41 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Q30-33 Access to water (quality and quantity) Q30 Main source of drinking water 1 =piped 2= Unprotected well 3= Water catchments 4= Protected well, boreholes or spring 5 = River 9=other ____________ Q31 Average time taken to and from the nearest water point (including waiting and collecting time) 1= <30 min 2=30 – 60 min 3= 1-2 hrs 4= more than 2 hrs Q32 Number of water collecting and storage containers of 10-20 litres in the household: 1=1-2 containers 2= 3-4 containers 3=4-5 containers 4= more than 5 Q33 What is the method of water storage in the household? 1=Covered containers 2=Open containers 3=Constricted neck/end (Ashuun) Q34-40 Sanitation and Hygiene (access and quality) Q34 Type of toilet used by most members of the household: 1=Improved pit latrine (VIP) 2=Traditional pit latrine 3=Open pit Q35 Distance between toilet and water source 1=0- 30 metres 2=30 metres or more Q36 what washing agents do you use in your household? 1=Soap 2=Shampoo 3=Ash 4=Plant extracts Q37 How do you store prepared food? 1= Suspend in ropes/hooks 2=Put in pots beside the fire 3= Put in covered containers specify _____ 4=Designated area 5=Bush 5=None 4= Don’t store 5= Other, Q 38 Food Consumption Diversity Twenty four-hour recall for food consumption in the households: The interviewers should establish whether the previous day and night was usual or normal for the households. If unusual- feasts, funerals or most members absent, then another day should be selected. 42 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Food group consumed: What foods groups did members of the household consume in the past 24 hours (from this time yesterday to now)? Include any snacks consumed. Did a member of your household consume food from any these food groups in the last 24 hours? 1=Yes 0=No Type of food 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Codes: 6=Borrowed 7=Gathering/wild 8=Others, specify_______ 9=N/A 1= Own production 2=Purchases 3=Gifts from friends/families 4=Food aid 5=Bartered What is the main source of the dominant food item consumed? (Use codes above)? Cereals and cereal products (e.g. maize, spaghetti, pasta, caanjera, bread)? Meat, poultry, offal (e.g. goat/camel meat, beef; chicken/poultry)? Eggs? Roots and tubers (e.g. potatoes, arrowroot)? Vegetables (e,g, leafy vegetables, tomatoes, carrots, onions)? Fruits (e.g. water melons, mangoes, grapes)? Pulses/legumes, nuts (e.g. beans, lentils, green grams, cowpeas)? Milk and milk products (e.g. goat/camel/ fermented milk, milk powder)? Oils/fats (e.g. fat, butter, ghee, margarine)? Sugar and honey? Fish and sea foods (e.g. fired/boiled/roasted fish, lobsters)? Miscellaneous (e.g. spices)? ______________ Q39 In general what is the main source of food in household? Q40 Total number of food groups consumed (filled by enumerator): __________________________ Q41 - 42 Informal and formal Support or Assistance in last three months (circle all options that apply) Q41 Which of these informal supports did you receive in last three months 1=Zakat from better-off households 2=Remittances from Abroad 3=Remittances from within Somalia 4=Gifts 5=Loans 6=None 7=Other (specify) ____________________ Q42 Which of this formal international or national aid support did you receive in last three months? 1= Free cash 2=Free food 3=Cash for work 4=Food for work 6=Water subsidy 7 Transportation of animals subsidy 8=Veterinary care 43 5=Supplementary food 9=None 10=Other (specify) _______________ Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 7.6APPENDIX 5: QUESTIONNAIRE FOR QUALITATIVE DATA (Data collected through: key informant interviews, focus group discussions, literature review, general observation) Name of facilitator____________ No. of participants in focus group (Males/Females)_____________________ Area/Location _________________________ Livelihood 15 ___________________________________ a). Population and Demography (Key informants, direct observation and literature review) • Estimated population size of a) town/village • Is there any unusual population movement in or around this site? _______________________________________ • If yes from ------------------------ , To:----------------------------- • What is the estimated number of households that have moved a) Into the area_____ b) Out of the area _______ • Who is moving? • Who is not moving ? __________________________________________________________________________ b) If sampled population if different_________________ ___________________________________________________________________________ What is the cause of the unusual population movement? a) Security scarcity b) Food shortage c) Water d) others, specify : What is the effect of the unusual movement on people’s overall well being (health, nutrition, lives)? b) Food security • What is the current main source of food for the households? • What is the current main source of income for the households? ______________________________ _____________________________ Has there been any change in the source of household food in the last three months? Yes/No If yes, what is the change? Has there been any change in the source of household income in the last three months? Yes/No If yes, what is the change? Has the change in the means of access to food and income in the last three months affected the food consumed? Yes/No/Not applicable. If yes, explain how? 15 A livelihood comprised the capabilities, assets, activities and strategies required and pursued by households and individuals for a means of living (FSAU 2005) 44 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP 45 Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP c) Identify the most commonly applied coping strategies by the poorest households, in the last three months (Administer the relevant coping strategies for each specific livelihood) Coping strategy Questionnaire – Pastoralist Livelihood In the past 30 days, if there have been times when you did not have enough food or money to buy food, has your household had to: a. Reduce home milk consumption and sell more of milk produced? b. Consume less preferred cereals c. d. e. Borrow food on credit from another household (Aamah)? Reduce number of meals per day? Reduce the portion size/quantity consumed at meal times (Beekhaamis)? f. g. h. Rely on food donations (gifts) from the clan/community (Kaalmo)? Consume weak un-saleable animals (caateysi)? Send household members to eat (for food) elsewhere? i. j. k. Skip (go an) entire days without eating (Qadoodi)? Beg for food (Tuugsi/dawarsi)? Rely on hunting for food (ugaarsi)? Coping strategy Questionnaire – Agro-pastoralist Livelihood In the past 30 days, if there have been times when you did not have enough food or money to buy food, has your household had to: a. Shift from high priced cereal varieties to low price cereal varieties? b. Shift from high quality cereals to low quality cereals (from osolo to obo)? c. d. e. f. Borrow food on credit from shop (Deyn)? Borrow food on credit from another household (Aamah)? Reduce home milk consumption and sell more of milk produced? Reduce the number of meals in a day by adults? g. h. i. j. Stop all home milk consumption and sell all milk produced? Rely on food donations (gifts) from the close relatives (Qaraabo)? Rely on food donations (gifts) from the clan/community (Kaalmo)? Skip (go an) entire days without eating (Qadoodi)? k. l. Community identified your household as in need of food and fives support? (Qaraan) Send household children to live or eat with relatives (elsewhere)? 46 1= Yes 2=No 1= Yes 2=No Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Coping strategy Questionnaire – Riverine Livelihood In the past 30 days, if there have been times when you did not have enough food or money to buy food, has your household had to: a. Shift to less preferred foods (e.g. white maize to yellow maize)? b. Reduce the portion size/quantity consumed at meal times (Beekhaamis)? c. Consume poor quality foods (unsafe or spoilt)? d. Reduce number of meals per day by one (e.g. from three to two)? e. f. g. h. i. j. k. Consume wild foods and fish from the river? Consume immature crops (fruits or cereals)? Reduce number of meals per day by two (e.g. from three to one)? Feed particular members (elderly, children) at the expense of other household members? Consume seeds meant for future planting? Borrow food for consumption (to be repaid in future – in kind)? Eat prohibited/ unacceptable foods (animal skins, grass, roots, clotted blood, tree leaves, warthogs, etc)? 47 1= Yes 2=No Buale Sakow Districts Nutrition Assessment, April 2006 FSAU/\WVI/UNICEF/WFP Baseline Data (collect on first visit and then only if the situation has changed from the preceding months) b). Shelter: (Observation and key informant interviews) • What is the kind of shelter /houses used by the communities in this site? a) grass thatched mud houses b) other specify Currently, is there any change in the kind of shelter/houses, the affected community resides in? If yes, what is the change? c). Water and Sanitation (Household interviews, observation, visits to water points, FGD) • What is the usual source of water for this community? a). protected well b). un-protected well c). water catchments • d) river e)other, specify ___________ Where is fecal matter disposed of? a) latrines _____ b) bush ___ c) Other __________________(specify) Has there been any change in the source of water in the past three months? If yes, please specify: Has there been any outbreak of diarrheal diseases in the past three months? If yes, please specify: d) Health Issues • Where do the affected households seek for health assistance when sick? • a) Hospitals ____ b) MCH/OPD ______ c) Health posts _____ d) private clinic/pharmacy _____e) traditional • f) Other specify _____________________ If no, why? a) Long distance to the health institution b) other specify ___________________ Are there particular groups of people whose health problems are especially bad? Yes/No If there is, in what ways? Reasons: Has there been any disease outbreaks in the in the area in the last three months? Yes/No If yes, please explain: e) Education • Are there any formal schools/educational institutions in this area? Has there been any dropout from schools/educational institutions in the past three months? Yes/No If yes, indicate the reasons: 48 8. ASSESSMENT TEAM Serial No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Name Adan Moalim Hassan Ali Ibrahim Magan Abdullahi Hassan Awdahir Kadar Osman Rashid Ayhanshe mohammed Husein Ayan Adan Bile Abdi Adan hassan Ahmed Adan Osman Liiban Abdi Sanior Ibrahim Ahmed ibrahim Mohamud Mohamed moalim Fadumo ají Osman Rukiya Idle Adan Kaadro mohamed Ali Abdirahaman Bare Dubad Abdiker Sheik Bashir Kariye Nunow Ali Moalim Ugas Isaak Mohamed Abdi Ali Ibrahim Moalim Abdirahaman Abdulahi Shidiye Dhagane Adan Ibrahim Isaac Safia Dhagane Hanshi Adan Ali IBrahim Said issk Kalmoy Ajéis Sheik Mohamed Farah Bile Mohamed Ibrahim A Hussein Mohamed Hassan Gani Khaliif Nouh Abdullah Ibrahim Mohamed Osman Warsame Josephine muli Mohamed Mudir Barnabas Okumu Hersi Mohamoud Abdirizak Peter Kingori Agency WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI WVI FSAU FSAU FSAU FSAU WVI WVI WVI WFP FSAU FSAU 41 Ahono Busili FSAU 42 Noreen Prendiville FSAU Role Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Enumerator Supervisor Supervisor Supervisor Supervisor Supervisor Supervisor Supervisor Supervisor Supervisor Data entry Data entry Data entry Trainer/Field supervisión and coordination Logistical coordination Logistical coordination Logistical coordination Aanalyzed the food security situation Analyzed the food security situation Nutritionist – Assisted in technical coordination, supervised data entry Coordinated the Assessment Data Análysis and report writing Provided Technical Advice, overall leadership and managerial support at all stages of the assessment 9. REFERENCES Nutrition Assessment Guidelines for Somalia: Nutrition Working Group, January 2005 FSAU Monthly Nutrition Update March 2006 Measuring Mortality, Nutrition status and Food Security in Crisis Situations: SMART Methodology FSAU 2005/06 Post Deyr Analysis, February 2006